The Authorization Denials Appeals Nurse is responsible for managing authorization denials by conducting a comprehensive analytic review of clinical documentation to determine if an appeal is warranted. Analyze pre- and post-service authorization denials to determine if there is clinical justification to submit a request for retro-authorization. Serve as a clinical resource to the Central Authorization Unit and provide peer-to-peer reviews when the payer allows a nurse to participate in the process. Write sound, compelling factual arguments for appealing authorization denials. Maintain a detailed knowledge of Third-Party Payers’ and Governmental Payers’ clinical/medical necessity/authorization criteria. File compliant appeals in accordance with third-party and governmental contracts. Screen denials for possible reconsideration, peer to peer, or formal appeal. Investigate denials and root causes and track and report trends to remediate issues and assist with internal process improvement. Prepare and submit appeals per payer guidelines. Leverage clinical knowledge and standard procedures to ensure timely attention to denials as requested by PFS. Assist in the research and application of regulatory policies to support administrative appeals. Communicate pertinent clinical information to Physicians, Medical Directors, and other members of SCMG regarding evaluation of payer determinations. Educate other departments regarding payer changes and denial/appeal process. Understand clinically complex medical situations and communicate appropriately with insurers as needed. Utilize working knowledge of basic coding guidelines for medical necessity and insurance authorization escalations and/or denials. Maintain expert knowledge of how to navigate payer websites to validate insurance eligibility and authorization requirements. Determine the method in which a payer requires appeal submission. This is not an all-inclusive list of this job’s responsibilities. The incumbent may be required to perform other related duties and participate in special projects as assigned.